Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Wednesday, April 29, 2009

Furious Seasons has a rather distressing piece of news from a recent Bristol-Myers Squibb conference call. To sum it up quickly, BMS claims that 10.6% of depressed patients are now receiving atypical antipsychotics. Of those 10.6%, 21.7% are taking Abilify. So that would mean roughly 10-11 in 100 depressed patients are taking antipsychotics and 2 of them are on Abilify. I shudder to think how many are on Seroquel. Or Zyprexa. It made me think of a post I wrote a few weeks ago in which I described the marketing of Abilify for depression. A huge market of depressed people just ripe for the picking.

Going along with this, BMS is pushing back on the issue of akathisa, the side effect that has garnered the drug much bad publicity (at least in the blog world; 1, 2, 3) via a medical journal article that distracts attention from Abilify as an akathisia-inducer. More on that to come soon. Ghostwriters, ignoring contradictory evidence; basically, an attempt to completely obscure the evidence on the topic. It's not the first time BMS has successfully placed a study with major flaws into a medical journal (1, 2). Details will be forthcoming.

15 comments:

First, I'm a psychologist, not a physician, so I don;t prescribe medications. However, many of my clients who do not respond fully to antidepressant medications have clearly benefitted from the addition of a small amount of the unfortunately named "atypical antipsychotics". When used in this way, patients are not being given the kinds of doses that would be prescribed for schizophrenia or bipolar disorder, but rather very small "starter" doses. The benefits accrue from the "serotonin boosting" properties (and possibly direct or indirect effects on other neurotransmitters as well) of the atypical antipsychotics which supplement the effects of the antidepressant without having to increase the SSRI or SNRI to the point where side-effects would become problematic.

I won't deny that many patients might a) take an antipsychotic, then b) feel less depressed afterward.

But how much of the improvement is simply a placebo effect? Most of it. Look at the research and it's pretty clear that a combo of a placebo effect and the passage of time is responsible for the good majority of improvement. No study compared Abilify to switching antidepressants or (gasp) adding psychotherapy, and I'd guess either would work as well or better.

So while I appreciate your views, we have to keep in mind that we do research for a reason. And there is not a shred of evidence suggesting that adding an atypical is better (or even as good as) switching treatments or adding a safer augmenting agent.

The patients to which I referred are already in psychotherapy. There are patients who require both, despite claims to the contrary. And some have tried other "augmenting agents" with little benefit.

I'm well aware of the limitations of anectdotal or observational findings. I have a substantial research background with several publications in peer-reviewed journals. I'm also well aware that with psychopharmacological research, aggregated (group) data can hide true benefits because of the presence of different and sometimes opposite effects or side-effects in different individuals. What I have personally observed are not placebo effects, especially since in some cases I have had the opportunity to see A-B-A comparisons where the added medications have been stopped for a period of time and then re-added.

I'm also not suggesting that every depressed patient requires these kinds of medications. Adding ANY medication into the picture creates the risk of unwanted side-effects. The patients I am discussing typically have tried a variety of medications - again, in combination with psychotherapy - and have continued to struggle. And some of those patients HAVE responded positively to the addition of a small amount of Risperdal or Abilify or Seroquel.

Despite what you may have been taught in school or what you may have been led to believe, CBT cannot do everything.

If we take it as a give that augmentation is the way to go, what we need are comparative trials- not trials that simply demonstrate that the null hypothesis of placebo=atypical is false in the absence of an impressive effect size.

What happened to augmentation with buspirone, for instance?

Oh, it's off-patent now, and there's no money to be made from it anymore...

Believe me, I am not a true believer in CBT or any other mode of psychotherapy. No single treatment is going to work for everyone - I get that. And I'm also not saying that absolutely nobody benefits from atypicals in depression. A very wide variety of treatments work in reducing depressive symptoms. Some have more risks than others.

I'm just sayin' that the published research for atypicals in depression is quite weak, and that the adverse events are not a pretty picture. So unless the science gets a lot better, I think that other treatments are a better idea. I can't agree or disagree with your clinical observations; you see what you see and I appreciate the value of clinical observations. At the same time, I get really nervous about anecdotal evidence becoming the basis of medicating millions of people with atypicals. Is that so crazy?

Anon - your comments about a generally unimpressive effect size are similar to my views on the topic. Oh, buspirone, what fun would THAT be when you could whip out Abili-prex-oquel?

Lobotomy worked by removing the patients brain. Removing the ability to think about ones problems with a powerful tranquilizer might indeed cure depression. Thank you God for removing your patients humanity because the human condition is now a medical condition.

What absolute nonsense! First, Abilify is not "a tranquilizer tranquilizer"; it's not a tranquilizer at all - it doesn't even remotely resemble a tranquilizer. Second, tranquilizers aren't used to treat depression and would probably make the depression worse if it were used for that purpose. And third, depression is NOT "the human condition". If it is YOUR condition, I would advise you to do something about it by consulting a professional who actually knows what s/he is talking about.

And by the way, lobotomy has not been used in many decades but even when it was in use it did not "remove the patient's brain". It was hardly precision surgery and it was certainly not a treatment that anyone would recommend today but it only affected the frontal lobes. I would also add that part of the reason it is no longer used is that we now have pharmaceuticals to treat the conditions that previously might have resulted in the use of a lobotomy.

Depression is not new to human beings is what I meant . Mankind has been suffering from it from the start of time. It used to be called Sloth. A refusal to enjoy the good things in the world. A legal chemical a psychiatrist prescribes is no better than (good quality)illegal chemicals or alcohol. Medications are a temporary fix, if they work, and if they work safely, which often they don't, as the patient often doesn't know how to deal with or handle the relentless forced chemical feelings.

re: "Typical antipsychotics are also sometimes referred to as tranquilizers, because some of them can tranquilize and sedate."

That's like saying "Alcohol and cannabis are sometimes called antidepressants because they can sometimes temporarily relieve depressed feelings". Show me someone other than a lay blogger who calls atypical antipsychotics "tranquilizers".

re: "In China yes they still do lobotomies."

They also reportedly eat dogs, abort female foetuses, and run students over with tanks. And your point is?

re: "Depression is not new to human beings is what I meant . Mankind has been suffering from it from the start of time. It used to be called Sloth. A refusal to enjoy the good things in the world."

If you truly believe that major depression is a "refusal to enjoy the good things in the world", further discussion is pointless.

re: "A legal chemical a psychiatrist prescribes is no better than (good quality)illegal chemicals or alcohol."

That is nonsense. There is a huge difference between the effects of alcohol, cannabis, and other nonprescription drugs, and the effects of prescripotion antidepresants on depression and on the depressed brain. I strongly urge you to stop pontificating about conspiracy theories and do a little research.

Re:China: "And your point is?"People performing brain damage are called Doctors just like here. Are they doctors or not? It is whoever is in power gets to decide what proper psychiatry is. Thats not science.

"Do a little research?" You are hilarious. I'm a depressed paranoid schizophrenic who doesn't take medication for my brain chemical imbalance.Do you know how much Thorazine I was forced to "take"? I've had plenty of research thanks bub.

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I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...